BORANG PENDAFTARAN KEAHLIAN MEMBERSHIP FORM
BORANG PENDAFTARAN KEAHLIAN MEMBERSHIP FORM
BORANG PENDAFTARAN KEAHLIAN MEMBERSHIP FORM
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PERPUSTAKAAN UNIVERSITI SAINS MALAYSIA<br />
UNIVERSITI SAINS MALAYSIA LIBRARY<br />
________________________________________<br />
<strong>BORANG</strong> <strong>PENDAFTARAN</strong> <strong>KEAHLIAN</strong><br />
<strong>MEMBERSHIP</strong> <strong>FORM</strong><br />
RUJ<br />
REF<br />
:<br />
:<br />
Sila guna huruf BESAR apabila mengisi borang.<br />
Please write in CAPITAL LETTERS.<br />
Nama Name: _________________________ No. Matrik/Staf:<br />
Matric / Staf no:<br />
Alamat Rumah<br />
Home Address:<br />
____________<br />
______________________________________________________<br />
_____________________________________________________<br />
2 keping gambar<br />
berukuran<br />
pasport<br />
2 passport size<br />
photos<br />
Alamat Pejabat<br />
Desasiswa<br />
Office Address:<br />
______________________________________________________<br />
______________________________________________________<br />
Telefon (Rumah)<br />
Telephone (House):<br />
_________________________<br />
(Pejabat)<br />
(Office):*<br />
____________________________<br />
Telefon bimbit<br />
Telephone (Mobile):<br />
________________________<br />
Emel Email: ________________________________<br />
Tarikh Lahir<br />
Date of Birth:<br />
_________________________<br />
No. MyKad / Pasport<br />
MyKad no. / Passport:<br />
______________________<br />
Pusat Pengajian/Jabatan School/Department:*<br />
___________________________________________<br />
Tahun<br />
Pengajian Year:*<br />
Jawatan<br />
Position:*<br />
___________________________ Kursus Course:* _________________________<br />
________________________________________________________________________<br />
Tarikh tamat pengajian/perkhidmatan:<br />
Date of completion / Expiry date of service/contract:<br />
____________________________________________<br />
Dengan ini saya bersetuju untuk mematuhi segala peraturan yang ditetapkan oleh pihak Perpustakaan.<br />
I hereby agree to adhere with the regulations as stipulated by the Library.<br />
Tandatangan<br />
Signature:<br />
______________________<br />
Tarikh<br />
Date:<br />
____________________________<br />
* Jika berkenaan If necessary
UNTUK KEGUNAAN PEJABAT OFFICE USE ONLY<br />
No. keahlian<br />
A. Kategori Keahlian (tandakan √ )<br />
1. Pelajar: 4. Publik:<br />
- Ijazah Pertama - Pesara USM<br />
- Siswazah Lanjutan - Alumni / Kerajaan<br />
- Pelajar Jarak Jauh - MIDAS / Swasta<br />
2. Akademik / Pengurusan Professional - Tanggungan<br />
3. Kakitangan Sokongan / Projek<br />
B. Jika keahlian tanggungan<br />
Nama staf: _______________________________________<br />
No. keahlian Perpustakaan: _________________________<br />
Pusat Pengajian / Jabatan: __________________________<br />
Sambungan Telefon: _______________________________<br />
Hubungan dengan pemohon (bulatkan):<br />
Suami / Isteri / Ibu / Ayah<br />
C. Bayaran<br />
1. Yuran pendaftaran: RM<br />
2. Yuran perkhidmatan: RM<br />
3. Yuran tahunan: RM<br />
4. Wang cagaran: RM<br />
JUMLAH<br />
RM<br />
No. resit: ________________________________________<br />
Keahlian sah sehingga: _____________________________<br />
Tarikh: ________________________________<br />
Tindakan oleh: ___________________________________<br />
Tarikh: ________________________________<br />
Semakan2/2010<br />
AIY/WEWMA/BSJULAI2009
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